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HomeMy WebLinkAbout14629 . � �'� �' IE'XF'!F°iEt) CITY OF DIAMOND�AI� �r�'� —��� DEPARTMENT OF CQMIVIUNITY&DEVELOPM SERVICES �-" 21660 E.Copley Urive Suike 190 �C� � � ?��Q PRESS ,,,,w (909)860-3195 F�e(909)Sb1-3117 � �vu.ntNc r��A'�r'LY�A�[or� . . , _ FIRMLY , _._.,. �..,�, ... . � JOBSITE , w. , . :: ..,.. . , ,c.;: o ADDRESS �� ��������,F�u p��I,J��� '�ATE�CATION NUMB R #/C � 5SUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p aWNER ' o ADDRESS L�` L� �% ZONMG SETBACKS W CI7Y �ZIP f��� T r � FRONT RW ❑ � APPLICANT T L��"'����� REAR C � SIDFJSIQE STREET RW ❑ � CONTRACTOR � 5��� � ADDRES ` � CITY�r°�1�i',�,�,�-�„�:.� ZI P � �T � PROPOSED U5E o ARCH/ENG/ i,; tiz DESIGNER NO.DWEI. NO. NO. d ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FAGTOR PSF ADJ.AREANA�UATION � � OWNER•BUILDER DECLARATION SFRlADDlREM O p 1 HERE9V AFFlRM UNDER PENALTY OF PERIURY 7HAT i AM EXEMPT FFOM TVIE�CONTRACTORS LI- G8f0QB/CflfpOff W CENSEIAWFORTHEWI.LOW�NGRFASON�SEC.7031.56U5MESSANOPROFES510F�5C0'DE:ANYCITYOR (n U CWMYWHICHREWIRESAPERMYfTOCONSTPUCT,ALTER,IMPflOVE,DEMOLISH,ORREPAIRANYS?AUC-' IW Patio/D6Ck WTUqE,PiiION TO ITS ISSUANCE,'AL50 REQUIRES THE AVPLICANTFOR SUCH PERMR Tb�ILE A SIGNED � SiA7EMENT THAT HE OR SHE 15 UCENSEO PURf+UANT TO 7HE PRdVISIOFS OF THE bdN4RACTOfiS CI- � CENSELAW(CHAPTER9(COMMENCINOWITHSECTIDN7oD0)OFOIVISION30FTHEBU$INESSAN�PpO- {'�' PooVSpa FESSqNS ODDE)Oti THAT HE OR SHE�5 EXRdVTTHEREfPOM AND THE BA813 FOR YHE ALCEaEO E%ENP� TKKJ.ANYVI(%ATIONOFSECTION7031•68YANYAPPLICANTFORAPEqMITSU&IECTSTFI,EAP7LICANiTO z Re-RoDf � ACMLVENALTYOFNDTMORETMANfIVEHUNDRE�iDOI.LAR51f5ou).): � ��� -��� � �I,/SC�MEROFTHEPqOPERNORMVEMPCOYEE54VITHWA6ESASTHEIR50LECd1APENSATWN, � COfnR16fGIdi WIU.OD THE WORIC M1D THE STRUCTURE IS'NOT INTENDED OR OFFERED FOit SALE(S�C.7046,BU51- .,J NESS AND M�qFE3310NS CODE:7HE CONTRACTORS LICENSE lAW DOE6 NOT APPLY TO AN OWN6R OF � PROPERTYNM1IOBUILDSORIIAPROVES7NEqEON,ANDWHO00E$SUCHWORNHIMSEIFOflHEFiSd.FOR � � TMq0U0HH13�ORHERONRJEMaLOVEES.PROVIDEDTHA'YSUCHIMPhOVEMENTSAtiEN67;INTENDE60R � Q ,OFFEREDWFSALEIF,FiOWEVERTMEBWLDINCaOF111APFlOVEMENTI55otDWRHIN6NEYEAROFCOMPCE- � TION,THE OWNER-BUILDER YNLL HAVE 7HE 6URDEN OF�ROVINO hIATNE OR�SNE DID NO78UIIA OR = IMPR9VEfORTHEPUHPOSEOF-SALEF . .. �'�� ' ....��'.,�.��.., O I.AS OWNER OF iHE PflOPERTY.AM E%CLU5IVELYCONTFlACTING WffFl LICENSED CbN7RACTd1S � TO CON67RUCT TiE PR0.)EbT(SEC.7a�6,BUSINE85 AND PROFES.�IONS CODE•THE CONYRACTOPS LI� Va1U8tI0n ADJ.AFEA � CENSEUIWDOESNO7APPLYTOANOWNEROFAPROPERTVWHOBU!LDSORIMhHfJb'ES7HEREON,AND WiIOCONTMCT5FOR5UCHPROJECTSWITHACONTRAC70R�S)LICENSEDPURSUAN7TOTFtECONYRAG QUANTITY DESCRIPTION FEE � TORSIICENSEUIW.). 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B.8 P.C.FOflTH15 R�ASqN Q 0 J '� � u' OATE ONMEH '___ z w �� '!� e � LICENSED CONTRACTORS DECIARATION�� �� - � –� � W IHEREBVAFKI(iMUNDERPENALYYOFPERJUMTHATIAMLICENSEDUNOEfiPROVI510N50FCNAP7ER �r � e(COMMENCMICi WffFISECTqN 7000�OF�IVISKKJ 90f THE BUSIHESS AND PROFES510N5 CODE,ANO X MYUCENSE IS IN FUl.I FOFlCEAND EFFECL m LLS /� }� o UCENSECLASS (�-���� LIC.NO.��.!�'� ! � J V pp7E .�'' CtlNTRACTOR.� n- W rt� WORKEFiS'COMPENSATION DECLARATION � � IHEFlEBYFFfiqMUNDEFiPENALTVOFPEfl.IURVONEOFTHEFo4�_OWINGOECURA N . — � � _INAVEANOWILLMAINiAYiACERTffICATEOPCONSEMiOSELF-INSUF ORWOFNfR COMPENSATION.ASPROVIOEDBYSECTION37o0C1FYHELA90RCO�E ORTHEPERFORMAN �� OFTHE WOPK FOR WN�CH THIS PEHMIi IS ISSUED. � 0 W �I NAVE ANO WILL MAIMAM WORKERS'COMPENSA710N INSURANCE,A SECTION � 37aDOFTHELABORCOOE,FORTHEPERFOPMANCEOFTNEWOHNFORNMI THISPERMITIS _ ISSLIED.MYWORKERS'COMPENSATIONINSUPANGECARRIERANDPOLIC UMBERARE: � O �� ,.,,J�. ��A�EA ��5,! , ; , , , N aEvi�w � POIICYNUM6ER �"'� GTR(C Q 0 (MISSECTOPJNE�NO7BECOhYLEfEDOFTHEPERWTISFOFiONE EDWL.tAAS(SWI�LESSI. PLUM G W 1 CERTIFY7HAT W THE PEAFORMANCE OF THE WORK FOK WHICH HIS PERAAIT IS ISSUcp.� HANICAL Z (3 SHALLNOTEMPLOVANYPERSONINANYMANNERSOA5T08E ESUBJEC7TO7HE �j WORKERS'COMPENSATIONLAWSOFCALIFbPNIA;ANDAGREETHA IFISNtlULOBECOME INSPECTIONFEE SU&IECTTOTHEWOiiKERS'COMPENSATIONPROVISIONSOFSECT 7000fTHELA80R ��� ♦ = ISSUANCE � �3 CODE,I3HALL FORTHWITH COMPLY WITH THOSE PROV1610NS. pppTE: � APPhiGANT: � SMIP ? W ENE'RGY P/C _�° ���""9��'�';u,�.ti���� J WAFNING:FAILURE TO SECURE WORKERS'COA9PENSATION COVERAGE 15 UNIAWFUL.AND SHALL BE yL � SIIHJECTANEMPLOYERTOCRIMMALPENALTIESPN�CNILFINESUPTOONEHUN�FEOTH�USAN� ENEHGYPERMIT b�'���,��.7.'�' ��j`~"�(-"'���'1� OOLLARS(5100,0o0),INADpITIONTOTHECOSTOFCOMPENSATION,DAMAGESASP(70VIDEOFORIN ,_ _, ,..��.-� - J SECTI�N 3108 OF iHE LA90R CQDE.INTEREST,AND AITORNEY'S FE�S. � RE7ENTION FEE: x Q a CONSTRUCTION LENDING A�ENCV � PRE-ALT FEE: � IHEflEBYAFFIRMUNDERPENALiYOFPERJURYh1ATTHEflEISACONSTRUCTIONLENDINCiAGENCV FOH THE PERFORMANCE OF TNE WORK FOR WNICH TH15 PERMIY i51SSUED(SEC.3087,CIV.C.). Z w � LENPER'SNAME . - 1— tENOER'SADDflESS - � ICERTIFYTHATIHAVEREADTHISAPPLICATIONPN�STATETHATTHEABOVEINFOFMATIONISCppRECT TOTALFEES �`�'� �' � IAGREETOCAMP�VYIRFIAILCITVANDCOUNTYOR0INANCESANDSTATEUWS-REUITINGT08UILD�NG - CONSTRUCTION,AN�HEREBV AUT}IORIZE REPRESENTATIVES OF iMIS COUNTY TO ENTER UPON THE � �.' A@OVE-MENT�ONEO PROPER7Y FOR INSPECTION PURPOSES. 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